Calderdale Tier 3 CAMHS (Child & Adolescent Mental Health Service)
Referral Form
Telephone:
01422 262 380 to discuss a concern/potential referral with the Tier 3 Duty Worker
Please post to: Tier 3 CAMHS, Laura Mitchell Health and Wellbeing Centre,
Great Albion Street, Halifax, West Yorkshire, HX1 1YR
About the Young Person
Name:
Also known as:
Date of birth:
NHS Number:
Male/female
Ethnicity:
First language:
Asylum seeker:
Have you seen the young
person?
Yes
No
Is the young person
aware of this referral?
Yes
No
Is the parent/carer aware
of this referral?
Yes
No
Has the parent/carer
consented to this referral?
Yes
No
Does the parent/carer
have parental
responsibility?
Yes
No
Yes
No
Yes
No
Home address:
Postcode:
Telephone:
Mobile:
Parent/Carers’ names:
Address of parent/carer (if
different from young
person)
Postcode:
If ‘NO’ then who holds
parental responsibility?
Has the person with
parental responsibility
consented to the referral?
If ‘NO’ then is the young
person deemed to be
Gillick competent
according to the Fraser
guidelines?
Relationship:
Siblings – name(s)/age
School/College
GP:
Surgery address:
Postcode:
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Revised version: December 2014
About the Referrer
Name:
Telephone:
Job title:
Mobile:
Agency:
Email:
Address:
Signature:
Date of referral:
Postcode:
Other people/agencies
involved:
Is there a CAF in place?
Yes
No
Yes
No
Past CAMHS involvement? (if yes, please attach details)
Yes
No
Is there a Child in Need or Child Protection Plan in place?
Yes
No
Is the young person in the care of the local authority?
Yes
No
If so please attach details and name of lead professional:
Does the child have a Statement of Special Educational Needs or similar?
If so please attach if available.
If yes, please give the name of the Local Authority responsible for providing care:
Name of Social Worker:
Reasons for referral, risk factors, and other agency involvement
(please attach any additional information that might be relevant)
SUICIDAL THOUGHTS?
Yes
No
Yes
No
Yes
No
Yes
No
If yes, please comment on severity/frequency:
HARM TO SELF?
If yes, please comment on severity/frequency:
HARM TO OTHERS?
If yes, please comment on severity/frequency:
SELF-NEGLECT?
If yes, please comment on severity/frequency:
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Revised version: December 2014
REFERRER’S CONCERNS & EXPECTATIONS:
What is the particular issue you are seeking help or advice about? Please give details of emotional or mental health difficulties, when these
started, and how these are affecting the child/young person. Please describe the current situation, relevant background information, how the
problem is seen at school and at home, what interventions have been tried etc.
SPECIALIST NEEDS:
Please identify any risk factors and specialist needs e.g. safeguarding concerns, poor mobility, sensory impairment, learning difficulties, literacy
problems, substance misuse, need for interpreter, parental agoraphobia or risk of violence.
YOUNG PERSON’S CONCERNS & EXPECTATIONS:
PARENTAL CONCERNS & EXPECTATIONS:
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Revised version: December 2014